Elliot Levy

Uterine artery embolization for leiomyomata

Abstract Objective: To determine whether uterine artery embolization is safe and effective for treating uterine leiomyomata. Methods: We analyzed 200 consecutive patients (61 reported previously) undergoing uterine artery embolization for the treatment of uterine leiomyomata at a single institution. After treatment, follow-up data were obtained by written questionnaire mailed to the patients at intervals of 2 weeks, 3 months, 6 months, and 12 months after treatment. Follow-up imaging was obtained at 3 months and 12 months after therapy. All complications and subsequent gynecologic interventions were recorded prospectively, obtained using the patient questionnaires and physician contact. The percentages and their 95% confidence intervals (CI) were calculated to compare the symptoms at follow-up. Proportional odds models for repeated ordinal responses were used to assess the stability of symptom improvement over time. Results: The mean follow-up was 21 months (minimum 12). Heavy menstrual bleeding improved in 87% (95% CI 82%, 92%) of patients at 3 months and in 90% (95% CI 86%, 95%) at 1 year after therapy. Bulk symptoms improved in 93% of patients (95% CI 88%, 96%) at 3 months and in 91% (95% CI 86%, 95%) at 1 year after treatment. Only one major periprocedural complication occurred (pulmonary embolus), which resolved with anticoagulant therapy. Subsequent gynecologic interventions occurred in 10.5% of the patients (95% CI 7.0%, 15.0%) during the follow-up period. Conclusion: Uterine artery embolization is safe and controls the symptoms caused by leiomyomata in most patients.

Radical stereotactic radiosurgery with real-time tumor motion tracking in the treatment of small peripheral lung tumors

BackgroundRecent developments in radiotherapeutic technology have resulted in a new approach to treating patients with localized lung cancer. We report preliminary clinical outcomes using stereotactic radiosurgery with real-time tumor motion tracking to treat small peripheral lung tumors.MethodsEligible patients were treated over a 24-month period and followed for a minimum of 6 months. Fiducials (3–5) were placed in or near tumors under CT-guidance. Non-isocentric treatment plans with 5-mm margins were generated. Patients received 45–60 Gy in 3 equal fractions delivered in less than 2 weeks. CT imaging and routine pulmonary function tests were completed at 3, 6, 12, 18, 24 and 30 months.ResultsTwenty-four consecutive patients were treated, 15 with stage I lung cancer and 9 with single lung metastases. Pneumothorax was a complication of fiducial placement in 7 patients, requiring tube thoracostomy in 4. All patients completed radiation treatment with minimal discomfort, few acute side effects and no procedure-related mortalities. Following treatment transient chest wall discomfort, typically lasting several weeks, developed in 7 of 11 patients with lesions within 5 mm of the pleura. Grade III pneumonitis was seen in 2 patients, one with prior conventional thoracic irradiation and the other treated with concurrent Gefitinib. A small statistically significant decline in the mean % predicted DLCO was observed at 6 and 12 months. All tumors responded to treatment at 3 months and local failure was seen in only 2 single metastases. There have been no regional lymph node recurrences. At a median follow-up of 12 months, the crude survival rate is 83%, with 3 deaths due to co-morbidities and 1 secondary to metastatic disease.ConclusionRadical stereotactic radiosurgery with real-time tumor motion tracking is a promising well-tolerated treatment option for small peripheral lung tumors.

Precision targeting of liver lesions using a novel electromagnetic navigation device in physiologic phantom and swine.

Radiofrequency ablation of primary and metastatic liver tumors is becoming a potential alternative to surgical resection. We propose a novel system that uses real-time electromagnetic position sensing of the needle tip to help with precision guidance into a liver tumor. The purpose of this study was to evaluate this technology in phantom and animal models. Using an electromagnetic navigation device, instrumented 18 g needles were advanced into radioopaque tumor targets in a respiratory liver phantom. The phantom featured a moving liver target that simulated cranio-caudal liver motion due to respiration. Skin-to-target path planning and real-time needle guidance were provided by a custom-designed software interface based on pre-operative 1 mm CT data slices. Needle probes were advanced using only the electromagnetic navigation device and software display. No conventional real-time imaging was used to assist in advancing the needle to the target. Two experienced operators (interventional radiologists) and two inexperienced ones (residents) used the system. The same protocol was then also used in two anesthetized 45 kg Yorkshire swine where radioopaque agar nodules were injected into the liver to serve as targets. A total of 76 tumor targeting attempts were performed in the liver phantom, and 32 attempts were done in the swine. The average time for path planning was 30 s in the phantom, and 63 s in the swine. The median time for the actual needle puncture to reach the desired target was 33 s in the phantom, and 42 s in the swine. The average registration error between the CT coordinate system and electromagnetic coordinate system was 1.4 mm (SD 0.3 mm) in the phantom, and 1.9 mm (SD 0.4 mm) in the swine. The median distance from the final needle tip position to the center of the tumor was 6.4 mm (SD 3.3 mm, n=76) in the phantom, and 8.3 mm (SD 3.7 mm, n=32) in the swine. There was no statistical difference in the planning time, procedure time, or accuracy of needle placement between experienced and inexperienced operators. The novel electromagnetic navigation system allows probe delivery into hepatic tumors of a physiologic phantom and live anesthetized swine. The system allows less experienced operators to perform equally well as experienced radiologists in terms of procedure time and accuracy of needle probe delivery.

Electromagnetic tracking for abdominal interventions in computer aided surgery

Electromagnetic tracking has great potential for assisting physicians in precision placement of instruments during minimally invasive interventions in the abdomen, since electromagnetic tracking is not limited by the line-of-sight restrictions of optical tracking. A new generation of electromagnetic tracking has recently become available, with sensors small enough to be included in the tips of instruments. To fully exploit the potential of this technology, our research group has been developing a computer aided, image-guided system that uses electromagnetic tracking for visualization of the internal anatomy during abdominal interventions. As registration is a critical component in developing an accurate image-guided system, we present three registration techniques: 1) enhanced paired-point registration (time-stamp match registration and dynamic registration); 2) orientation-based registration; and 3) needle shape-based registration. Respiration compensation is another important issue, particularly in the abdomen, where respiratory motion can make precise targeting difficult. To address this problem, we propose reference tracking and affine transformation methods. Finally, we present our prototype navigation system, which integrates the registration, segmentation, path-planning and navigation functions to provide real-time image guidance in the clinical environment. The methods presented here have been tested with a respiratory phantom specially designed by our group and in swine animal studies under approved protocols. Based on these tests, we conclude that our system can provide quick and accurate localization of tracked instruments in abdominal interventions, and that it offers a user-friendly display for the physician.

Liver Tumor Biopsy in a Respiring Phantom with the Assistance of a Novel Electromagnetic Navigation Device

The purpose of this study was to evaluate our ability to insert magnetically tracked needles into liver phantom tumors which move simulating physiologic respiration. First, a novel image-guided platform based on a new magnetic tracking device (AURORA?) was constructed. Second, an accuracy evaluation of a compatible magnetically tracked needle (MagTrax) was performed. Finally, 16 liver tumor punctures were attempted using only the image-guided platform for guidance. The inherent MagTrax needle positional error was 0.71?0.43 mm in the non-surgical laboratory setting. Successful puncture of liver tumors was achieved in 14 of 16 attempts (87.5%) by two users. The average time of each procedure was short (163?57 seconds.) The system adequately displayed the moving liver allowing for tumor target visualization and targeting. The AURORA based navigation platform and the compatible MagTrax needle appear promising for more rigorous phantom accuracy studies and in vivo tumor puncture testing in a respiring animal.

Uterine Artery Anatomy Relevant to Uterine Leiomyomata Embolization

Abstract To categorize the anatomic variants of uterine arteries, and determine the incidence of menopausal symptoms where the tubo-ovarian branches were seen prior to embolization. Between July 1997 and June 2000, 257 (n = 257) uterine fibroid embolizations were performed at our institution. Arteriograms were retrospectively evaluated. Uterine arteries were classified into groups: type I (the uterine artery as first branch of the inferior gluteal artery), type II (the uterine artery as second or third branch of the inferior gluteal artery), type III (the uterine artery, the inferior gluteal and the superior gluteal arteries arising as a trifurcation), type IV (the uterine artery as first branch of the hypogastric artery), inconclusive, or not studied. Tubo-ovarian branches were recorded if visualized prior to and/or after embolization. Menopausal symptoms were recorded (n = 175 at 3 months, n = 139 at 6 months, n = 98 at 1 year, n = 22 at 2 years) using written questionnaires. Five hundred and fourteen uterine arteries (n = 514) were evaluated. There were 38% classifiable types, 23% inconclusive, and 39% not studied. Classification was as follows: type I, 45%; type II, 6%; type III, 43%; type IV, 6%. Among 256 patients, tubo-ovarian arteries were seen in 36 prior to embolization, but not afterwards. In this group, 25 patients reported transient menopausal symptoms (hot flashes, amenorrhea). Five patients did not report any menopausal symptoms. Six patients did not answer the questionnaires. Type I is the most common type of anatomy, followed by type III. The tubo-ovarian arteries may be visualized prior to and/or after embolization. The embolization was monitored to avoid embolization of the tubo-ovarian branches. Menopausal symptoms were transient all patients when the tubo-ovarian branches were seen prior to embolization.

Influence of radiographic technique and equipment on absorbed ovarian dose associated with uterine artery embolization.

PURPOSE To evaluate the influence of pulsed fluoroscopy (PF), nonpulsed fluoroscopy (NPF), and various fluoroscopic techniques on the absorbed ovarian dose (AOD) associated with uterine artery embolization (UAE) of leiomyomata. MATERIAL AND METHODS Ovarian location was estimated from preprocedural pelvic magnetic resonance images of 23 patients previously treated by means of UAE. The AOD was measured with thermoluminescent dosimeters (TLD) placed into an anthropomorphic phantom at the determined ovarian location. The following measurements from PF and NPF were obtained: 21.89 minutes of nonmagnified posterior-anterior fluoroscopy, 10 minutes of nonmagnified oblique fluoroscopy, 10 minutes of posterior-anterior magnified fluoroscopy, 10 minutes of combined oblique magnified fluoroscopy, and 47 simulated angiographic exposures. Numbers for nonmagnified posterior-anterior fluoroscopy time and exposure numbers were chosen from the average values from previous UAE procedures. AOD from pulsed and nonpulsed nonmagnified posterior-anterior fluoroscopy was compared to measurements from oblique magnified, posterior-anterior magnified, and oblique fluoroscopy. RESULTS AOD from NPF was, on average, 1.7 times higher than from PF. When compared with nonmagnified posterior-anterior fluoroscopy, the AOD from oblique magnified fluoroscopy was 1.9 times greater; the AOD from nonmagnified oblique fluoroscopy was 1.1 times greater. The AOD from oblique magnified fluoroscopy was 1.5 times higher on the side closer to the x-ray tube than on the contralateral side. AOD from serial angiographic exposures contributed only less than 7% to the total AOD for the average UAE procedure. CONCLUSIONS The AOD associated with UAE can best be reduced by limiting fluoroscopy time and the use of oblique or magnified fluoroscopy. Contribution of angiographic exposures to AOD is much less significant.

Simtuzumab treatment of advanced liver fibrosis in HIV and HCV-infected adults: results of a 6-month open-label safety trial

Chronic liver injury can result in fibrosis that may progress over years to end‐stage liver disease. The most effective anti‐fibrotic therapy is treatment of the underlying disease, however when not possible, interventions to reverse or slow fibrosis progression are needed.

Intraarterial lidocaine for pain control after uterine artery embolization for leiomyomata.

PURPOSE To evaluate the effectiveness of intraarterial lidocaine in controlling pain after uterine artery embolization (UAE). MATERIALS AND METHODS In this double-blind prospective study, patients undergoing UAE received preservative-free 1% lidocaine or saline solution (control) in the uterine arteries before embolization. Postprocedural pain was managed with patient-controlled intravenous morphine. Attempted doses, number of doses received, total morphine dose, and maximum pain numeric rating scale (NRS) score during the postprocedural hospitalization were recorded and compared. Three-month follow-up magnetic resonance (MR) imaging and symptomatic questionnaires were collected and compared. RESULTS Ten patients received lidocaine and eight patients received placebo. Moderate to severe vasospasm was noted in seven patients after lidocaine injection, whereas no vasospasm was noted in the placebo group (P =.004). Patients in the lidocaine group had lower NRS pain scores than those in the placebo group (P =.012), whereas there was no difference in morphine requirement between treated patients and control subjects. The study was terminated after 18 patients were treated as a result of unexpected vasospasm. CONCLUSIONS Intraarterial 1% lidocaine is associated with moderate to severe vasospasm. Lidocaine significantly lowers subjective pain, but there is no difference in analgesic requirements. The routine use of intraarterial lidocaine is not recommended for pain control until the long-term effects of vasospasm on outcome is known.

Development of a liver respiratory motion simulator to investigate magnetic tracking for abdominal interventions

We have designed and constructed a liver respiratory motion simulator as a first step in demonstrating the feasibility of using a new magnetic tracking system to follow the movement of internal organs. The simulator consists of a dummy torso, a synthetic liver, a linear motion platform, a graphical user interface for image overlay, and a magnetic tracking system along with magnetically tracked instruments. While optical tracking systems are commonly used in commercial image-guided surgery systems for the brain and spine, they are limited to procedures in which a line of sight can be maintained between the tracking system and the instruments which are being tracked. Magnetic tracking systems have been proposed for image-guided surgery applications, but most currently available magnetically tracked sensors are too small to be embedded in the body. The magnetic tracking system employed here, the AURORA from Northern Digital, can use sensors as small as 0.9 mm in diameter by 8 mm in length. This makes it possible to embed these sensors in catheters and thin needles. The catheters can then be wedged in a vein in an internal organ of interest so that tracking the position of the catheter gives a good estimate of the position of the internal organ. Alternatively, a needle with an embedded sensor could be placed near the area of interest.